• Posted June 8, 2022

COVID Breakthrough Infections More Likely in People Living With HIV

Even after vaccination, living with HIV ups the odds for COVID infection, new research shows.

The study found that vaccinated people living with HIV have a 28% higher risk of developing a "breakthrough" COVID infection compared to those who don't have the AIDS-causing virus.

That's the bad news. But there's good news, too: The overall risk for COVID infection among people vaccinated with at least the two primary doses remains low, regardless of their HIV status.

"We thought we might see an increase in the risk of breakthrough in people with HIV because of the impact of HIV on the immune system and the role of the immune system in responding to vaccination and infection from a virus like SARS-Cov-2," reasoned study author Keri Althoff.

So, the researchers weren't surprised to find "that about 4 in 100 people with HIV experience a breakthrough, compared to 3 in 100 people without HIV," said Althoff, an associate professor in the Johns Hopkins School of Public Health epidemiology department.

But it was a relief, she said, to see that nine months after vaccination, "the rate and risk of breakthrough is low among vaccinated people with and without HIV" -- around 4% in each group.

Her team analyzed data on nearly 114,000 COVID-vaccinated men and women, of whom 33,000 had HIV. Most were 55 years and up, 70% were white, and more than 9 in 10 were men.

The authors focused on COVID risk during the latter half of 2021, when the more contagious Omicron variant emerged. Althoff noted that breakthrough infections were higher across the board -- regardless of HIV status -- in December, when Omicron became the dominant strain.

Beyond identifying the 28% higher risk for a breakthrough infection among those with HIV, the researchers noted that certain individuals with HIV faced a higher infection risk than others. They included people under age 45, compared with those between 45 and 54. Risk was also higher among those who had not received a third (or booster) dose, and those with a prior infection.

Risk of breakthrough infection in folks with HIV also increased as their T-cell counts dropped. According to the U.S. National Library of Medicine, T-cells are critical infection-fighting white blood cells which are typically attacked by HIV. (When an HIV patient's T-cell count falls to an extremely low level, it is often a sign of transition to full-blown AIDS.)

Althoff said she and her colleagues "hypothesize that HIV-induced immune dysfunction may be playing a role in vulnerability to breakthrough COVID-19 illness."

For that reason, boosters may be critical for such patients, she said.

Currently, Althoff pointed out, third-dose boosters are recommended for those whose HIV is either untreated or advanced.

"To increase protection against breakthrough infections, all people with HIV may need an additional dose in their primary series," she noted.

That thought was echoed by Dr. Joel Blankson, a professor of medicine at Johns Hopkins Medicine, who was not part of the study.

Because the study showed a decrease in breakthrough infections in patients who had received a third vaccine dose, "it is important that people living with HIV get a booster dose when they are eligible," Blankson said. The U.S. Centers for Disease Control and Prevention has COVID vaccine guidelines here.

Additional research by Althoff's team suggests that hospitalization risk for breakthrough cases is higher among HIV-positive people compared to those without HIV. (Those findings are still under peer review and are not yet published.)

Her advice to those with HIV: "Get vaccinated. Get boosted. Keep living your life and scale up and down your mitigation strategies -- mask-wearing, attending indoor gatherings, etc. -- based on the amount of COVID-19 transmitting in your community, and your personal health status."

Dr. Thomas Gut is associate chair of medicine at the Zucker School of Medicine at Hofstra/Northwell in New York City.

"The HIV-linked risk of reinfection is somewhat expected," said Gut, who had no role in the study. "In many other infectious diseases besides COVID, it's been known that patients with HIV do tend to have higher risk of both getting sick and having poorer outcomes."

But patients with HIV "that have strong immune cell counts have traditionally been known to be better protected from infections compared to those with low immune system counts," he added. "It appears that COVID reinfection risk follows this same pattern."

Therefore, Gut said, it is important to keep HIV infection under control as best as possible.

The findings are in the June 7 issue of JAMA Network Open.

More information

There's more on HIV status and COVID-19 at HIV.gov.

SOURCES: Keri N. Althoff, PhD, MPH, associate professor, epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore; Joel N. Blankson, MD, PhD, professor, medicine, Johns Hopkins Medicine, Baltimore; Thomas Gut, DO, associate chair, medicine, and director, ambulatory care services, Zucker School of Medicine at Hofstra/Northwell, Staten Island, N.Y.; JAMA Network Open, June 7, 2022